Purpose: To assess predictors of provider attitudes and counseling about trial of labor after cesarean (TOLAC).
Method: Cross-sectional, questionnaire-based study of OB/GYN providers (including residents, fellows, attending MD and CNM) at academic institutions (n=125). Eight clinical vignettes were presented and providers asked how they would counsel such a patient about TOLAC. In addition, information detailing respondent demographics, malpractice claims histories and experiences with cases of TOLAC complications was collected. Finally, respondents were asked to self-identify factors they felt influenced their counseling of patients considering TOLAC.
Result: 100% of respondants offer TOLAC in their practice. 53% of respondants reported that a majority of their patients with prior cesarean desired TOLAC. 42% of participants had been named in a lawsuit, and 55% had been involved in a case of uterine rupture. There was no significant difference in predicted likelihood of successful VBAC based on training level, years of experience, delivery volume, gender, past malpractice claims and involvement in cases of uterine rupture. Patient preference, plans for future childbearing, and provider prediction of successful VBAC were identified as the key factors affecting TOLAC counseling; however, more than 90% of respondents would offer TOLAC in 7 of 8 clinical scenarios regardless of prediction of success. Only 70% would offer TOLAC if a patient had 2 prior cesareans, and willingness to offer TOLAC decreased if induction of labor was required.
Conclusion: Patient preference is a key determinant of provider counseling regarding trial of labor after cesarean. While providers personalize counseling regarding TOLAC based on patient characteristics, most offer TOLAC regardless of predicted likelihood of success, suggesting that interventions to optimize integration of informed patient preference into a shared decision making process regarding approach to delivery in this context may be useful.
See more of: The 34th Annual Meeting of the Society for Medical Decision Making